A truly remarkable event today. Tom Insel, director of the National Institutes of Mental Health, decided to say out loud what he’s been saying quietly for a few years now: that the US Government has lost faith in the DSM. And the problem, he says, is not really the DSM-5, which he says will be little different from DSM-IV, and that this is the problem. Here’s his analysis
The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.
So the problem is the DSM itself, the way its descriptive approach can’t be anchored in something beyond itself, which is why none of the mental disorders it lists are valid. And, Insel concludes “people with mental disorders deserve better.”
This isn’t the first time Insel has gone public with his contention (which is virtually unassailable) that the DSM does not offer validity. He talked to me about this for The Book of Woe. “There’s no reality to depression or schizophrenia,.” he said. Indeed, the idea that there is a reality to them has dominated–and in Insel’s view hamstrung–research for more than three decades. “We might have to stop using terms like depression and schizophrenia because they are getting in our way.” And he didn’t stop there. “Whatever we’ve been doing for five decades,” he told me, “it ain’t working. And when I look at the numbers–the number of suicides, the number of disabilities, mortality data–it’s abysmal, and it’s not getting any better.. All the ways in which we’ve approached these illnesses, and with a lot of people working very hard, the outcomes we’ve got to point to are pretty bleak…Maybe we just need to rethink this whole approach.”
It’s a stinging rebuke, and the timing of his blog post makes it even more so. Two weeks before the DSM-5 comes out, Insel indicts the manual. It’s as pointed as it gets at his level: he’s taking the APA to task for not having found a way out of its “epistemic prison”– a term coined by Insel’s predecessr at NIMH, Steve Hyman, who first expressed these concerns in 1999. Hyman likened the job ahead to repairing an airplane while it is flying. Now Insel has suggested that we all might be better off if they just landed the thing and let the passengers look for another flight.
This episode reminds me of a beloved former professor of physiology during my preclinical education: On hearing about some new administrative scheme dressed as an innovation, he gruffly retorted, You’re not conducting an experiment, you’re just shuffling expediencies. It is ironic that NIMH made this announcement right when we learned there has been a major increase in suicide rates among middle aged males: http://tinyurl.com/bqhd3l4
The RDoC initiative exposes the intellectual poverty within NIMH. Science bureaucrats have no business messing in the steering of original science. Here they are being presumptuous and supererogatory. RDoC is a top-down solution to a bottom-up problem. Moreover, these same bureaucrats contributed greatly to the problem by allying themselves with the APA through previous iterations of the DSM. They even threw good money at the APA to help develop the DSMs.
RDoC would never have solved the problem of cerebral syphilis – dementia paralytica – with its pleomorphic symptomatic presentations. The 5 big domains of RDoC are metaphysical, scholastic constructs, which we can expect will devolve into something like the eccentrics and epicycles of 16th century astronomy. The cross-cutting notion (yawn) is a recycling of things Herman Van Praag began saying in the 1970s. Absent a clue about pathophysiology, the slick talk now about cross-cutting biomarkers is just biobabble, to use the term David Healy coined. I commented not long ago to Kapur and Insel that their approach would lump together Cushing disease, juvenile diabetes, pregnancy, anorexia nervosa, and adult onset metabolic syndrome because each of these displays abnormal glucose tolerance tests. I never heard back from them.
I commented a while ago that American psychiatry is irrelevant. Under its current leadership, NIMH also is irrelevant.
http://hcrenewal.blogspot.com/2012/11/does-american-psychiatry-matter.html
This took me by pleasant surprise, too, but a quick reading of Insel’s announcement chastened the schadenfreude it first inspired. The following seems to suggest that the NIMH is merely breaking up with the APA because the latter failed to produced their much-prophesied bio-markers. And I quote,
“Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior …. Mapping the cognitive, circuit, and genetic aspects of mental disorders”–and is it just me, or does imply the same tautological nosology you wrote about in _MD_?–“will yield new and better targets for treatment.”
Gary, do you read Insel’s post as a game-changer only with respect to the authority of the APA, or do you also see a potential blow to medico-industrial efforts to biologize psychic suffering? I have trouble seeing how the latter could result from the NIMH’s decision; it actually just seems like they’re trying to do the APA one better–declaring, let’s imagine, “These clowns never got around to breaking out the brain scanners, so now it’s up to us to finish what they started.”
Christopher Lane seemed to imply as much in a blog post this morning (http://www.psychologytoday.com/blog/side-effects/201305/the-nimh-withdraws-support-dsm-5), where your recent _New Yorker_ piece was favorably quoted. Thoughts?
1/ Tom Insel: “the DSM diagnoses are based on a consensus about clusters of clinical symptoms”
2/ Steven E. Hyman: “The approach for which I have argued is to focus the major efforts of the DSM revision not on individual diagnoses but on the assembly of larger clusters that could facilitate the application of modern neuroscience, psychology, and genetics to the understanding of mental disorders.” (…) [It is important] to treat clusters and meta-clusters, instead of individual DSM categories alone.
http://dana.org/news/cerebrum/detail.aspx?id=32066
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Are those two statements not contradicting with each other?